Health Care Fraud Strike Force

Regulatory scrutiny across the health care industry remains on the rise, with False Claims Act (FCA) and other civil and criminal health care fraud and abuse investigations at the epicenter of much of the activity.  The U.S. Department of Justice (DOJ) and Department of Health and Human Services Office of Inspector General (HHS OIG) are laser-focused on fighting health care fraud across the system, while more and more relators are filing – and litigating – qui tam actions even when the DOJ has declined to intervene in the case.

False Claims Act violations and other fraud and abuse allegations present a direct risk of treble damages and harsh, $5,500 – $11,000 per claim penalties, as well as program exclusion and the imposition of a corporate integrity agreement. Beyond statutory damages, FCA investigations and lawsuits can cause reputational harm to the health care provider or system having to fend off or defend against fraud and abuse charges. Individual officers and employees, and in some cases board members, may be in financial, civil or criminal jeopardy. Other collateral consequences may include shareholder derivative litigation, and parallel investigations and claims by state Attorneys General and by commercial insurance carriers, sometimes associated with RICO claims.

Health Care Fraud Strike Force: An Effective Response

Health Care Fraud Defense. On the front lines of some of the most high-profile health care fraud cases facing the industry today is Cadwalader’s Heath Care Fraud Strike Force. The Strike Force is a core group of seasoned attorneys who share a commitment to defending health care providers and systems faced with government investigations and claims of health care fraud. The Strike Force includes two former U.S. Attorneys and other former federal prosecutors who have prosecuted and defended major civil and criminal health care fraud cases and understand the tactics and tools at the government’s disposal and how best to address them. These former prosecutors work in tandem with additional Cadwalader health care litigators and regulatory attorneys serving on the Strike Force, each adept at litigating health care cases and addressing the challenges of a complex regulatory environment. Combined, this sophisticated team has deep and broad experience in conducting internal investigations and compliance reviews, responding to government audits and investigations, and defending claims of fraud, including:

  • FCA civil and criminal investigations led  by U.S. Attorney’s Offices around the country as well as the DOJ’s Civil Division in Washington, D.C.
  • State FCA investigations brought by state Medicaid Fraud Control Units, as well as whistleblower lawsuits
  • Investigations and audits by the OIG and state Medicaid Inspectors General
  • Medicare fiscal intermediary or administrative contractor audits and billing inquiries
  • RICO actions alleging fraudulent billing activity
  • Pharmaceutical misbranding charges and alleged violations of the Controlled Substances Act and Food Drug and Cosmetic Act

Health Care Compliance Counsel.  In addition to defending health care clients, attorneys on the Strike Force also proactively counsel providers and systems on preventing or mitigating the risk of fraud and abuse liability by performing internal investigations and compliance reviews; counseling clients on making self-disclosures to the government; assessing compliance program effectiveness; and developing and updating comprehensive and cost-effective internal compliance programs as new regulations and enforcement threats emerge.  Our clients include health care systems, prominent teaching hospitals, medical suppliers, long-term care provider networks, pharmaceutical companies, and insurers and managed care organizations.

The Strike Force Advantage

Strike Force attorneys are sensitive to all of the risks and ramifications faced by an organization that is the target or subject of a government investigation or claims of health care fraud and abuse.  We stay focused on our client’s broader business objectives.

Hallmarks of the Cadwalader Strike Force include:

  • Calibrated Size and Scope: The Strike Force is an agile and cohesive group of attorneys who have worked seamlessly together in the past to achieve favorable outcomes for our clients. In plain terms, we don’t throw an army of attorneys at a client matter. Strike Force attorneys calibrate the resources best suited to their needs so that each is served by a responsive, efficient and talent-strong team. Our health care group has its origins in representing not-for-profit clients in the 1980s, and the team’s provenance is reflected in its commitment to best practices.
  • Solutions Tailored to Client’s Needs: In the same vein, the Strike Force does not employ a “one size fits all” approach to defending or representing clients in False Claims Act and fraud and abuse matters. Rather, the client’s particular business needs and vulnerabilities shape and inform a legal strategy appropriate to the risks and individualized facts of each case and client.
  • Bench Strength: When the client’s needs or the case demands, the Strike Force can marshal the support of Cadwalader’s broader litigation team and the formidable resources and talents of a full-service, international law firm.

The Strike Force Track Record

Select recent False Claims Act and Fraud and Abuse engagements include:

  • NYS not-for-profit healthcare system in connection with an investigation conducted by the U.S. DOJ related to the alleged submission of Medicare reimbursement claims for medically unnecessary rehabilitation therapy services provided by a therapy vendor at affiliated nursing home facilities. The investigation recently settled without including allegations of FCA violations against our client. No Corporate Integrity Agreement was imposed by the DOJ.
  • Hospital in responding to and resolving a DOJ False Claims Act investigation into outlier Medicare reimbursement.
  • Health insurance company in an internal investigation into potential violations of the Anti-Kickback Statute.
  • Medical supplier to long-term care providers in the development of business and marketing policies and practices to comply with anti-kickback statute “safe harbors” and to mitigate risk of AKS liability.
  • Long-term care provider network and separately the board of a major pharmaceutical company in its compliance review and the development of recommendations for program enhancements.
  • Senior sales director of life science company in False Claims Act investigation involving off-label marketing of a medical device.
  • Long-term care providers in response to government audits and investigations seeking recovery of alleged overpayments.
  • Long-term care network and its affiliated nursing homes, home care agencies and managed long term care plan as compliance counsel.
  • Long-term care providers in connection with advice related to potential fraud and abuse practices, overpayments, and self-disclosures.
  • Insurer in a suit against numerous physicians and related practice groups alleging that the defendants engaged in sophisticated and related schemes to fraudulently obtain insurance proceeds that were supposed to pay for medical services for people injured in auto accidents.  The complaint alleged RICO violations, fraud, unjust enrichment, and related claims, including a declaration that the defendants were operating in violation of the law.
  • Insurer in a suit filed in the EDNY against providers of durable medical equipment (“DME”) alleging that these providers entered into arrangements with medical clinics and wholesalers to perpetrate a fraudulent scheme in which the providers submitted hundreds of fraudulent invoices to Allstate for reimbursement under New York’s no-fault law that grossly inflated the amounts the providers actually paid for the DME.
  • Senior sales director of life science company in False Claims Act investigation involving off-label marketing of a medical device.

Select recent pharmaceutical regulatory matters include:

  • The clubs of a professional sports league in connection with a DEA and DOJ investigation.
  • Chemical manufacturer and broker relating to compliance with DEA domestic sales and export regulations.
  • International manufacturer regarding registration, import and production quota issues.
  • National retail chain pharmacy regarding dispensing practices.
  • Major generic drug manufacturer and distributor in defending a civil action by DEA in federal court.
  • Several national wholesale distribution companies in litigation with DEA in federal court and before an administrative law judge.
  • Numerous employees of an international shipping company involved in the shipment of controlled substances in a federal criminal action.
  • National retail chain pharmacy regarding dispensing practices in a DEA investigation.
  • Large national generic drug manufacturer in the development of its DEA compliance policies.
  • Large wholesale distribution company in the design and implementation of its SOM compliance plan.
  • International manufacturer regarding import and production quota issues.
  • National retail chain pharmacy regarding its DEA anti-diversion and SOM compliance policies.

NEWS

RESOURCES

6 Attorneys

Avergun, Jodi L. Partner Washington
T. +1 202 862 2456
Campbell, Bret A. Partner Washington
T. +1 202 862 2253
Chin, Kathy Hirata Senior Counsel New York
T. +1 212 504 6542
McGovern, Brian T. Partner New York
T. +1 212 504 6117
Tompkins, Anne M. Partner Charlotte
T. +1 704 348 5222
Washington
T. +1 202 862 2496
Wainstein, Kenneth L. Partner Washington
T. +1 202 862 2474

Contact(s)

Brian T. McGovern
+1 212 504 6117 
brian.mcgovern@cwt.com
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Anne M. Tompkins
+1 704 348 5222 
anne.tompkins@cwt.com
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